Provider Demographics
NPI:1255411419
Name:BERGHOUT, BRYAN LEONARD (DPM)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:LEONARD
Last Name:BERGHOUT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6405 S 3000 E STE 201
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6990
Mailing Address - Country:US
Mailing Address - Phone:801-266-3113
Mailing Address - Fax:801-266-5633
Practice Address - Street 1:10821 19TH AVE SE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-5103
Practice Address - Country:US
Practice Address - Phone:425-337-7000
Practice Address - Fax:425-338-2408
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000813213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8484388Medicaid
WAU80616Medicare UPIN